Cardiology Practice Questions

Q: Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

Liver enlargement. ***Liver enlargement*** - **Hepatomegaly** is a reliable sign of **heart failure in infants** because the infant's liver is very compliant and readily distends with increased systemic venous pressure. - Due to a less developed compensatory mechanism, infants often manifest heart failure with signs related to **systemic congestion**, with liver enlargement being a primary indicator. *Pedal oedema* - **Pedal edema is uncommon in infants** with heart failure compared to adults, as they are often supine and have less hydrostatic pressure effect on their lower extremities. - When present, it might be due to other causes or a sign of very severe, chronic heart failure rather than an early or "sure" sign. *JVP* - **Jugular venous distension (JVD) is difficult to assess accurately in infants** due to their short, fat necks and the difficulty in positioning and visualizing the neck veins. - Therefore, it is generally considered an **unreliable physical sign** for diagnosing heart failure in this age group. *Basal crepitations* - **Basal crepitations (rales)** indicate pulmonary congestion and can be a sign of left-sided heart failure. - However, in infants, these can also be caused by **bronchiolitis**, **pneumonia**, or other respiratory infections, making them a less specific "sure sign" than liver enlargement.

Q: A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets "bluish" when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The combination of **pulmonary stenosis**, **ventricular septal defect**, **dextroposition of the aorta** (overriding aorta), and **right ventricular hypertrophy** is the classic definition of Tetralogy of Fallot. - The "bluish" episodes (cyanosis) when crying or feeding are characteristic of **tet spells**, indicating right-to-left shunting and reduced pulmonary blood flow, exacerbated by activity. *Atrial septal defect* - An ASD primarily involves a **left-to-right shunt** and typically presents with a **fixed, split S2** and a **pulmonic flow murmur**, usually without cyanosis in infancy. - It does not involve the characteristic four defects seen in this patient, particularly the significant pulmonary stenosis and cyanosis. *Coarctation of aorta, postductal* - **Postductal coarctation** typically presents in older children or adults with **hypertension in the upper extremities** and **diminished or absent femoral pulses**, often without cyanosis. - This condition is a narrowing of the aorta **distal to the ductus arteriosus** and does not involve the four specific intracardiac defects described. *Coarctation of aorta, preductal* - **Preductal coarctation** can present in neonates with **heart failure** and **differential cyanosis** (upper body pink, lower body blue), or signs of shock if the ductus arteriosus closes. - This condition involves a narrowing of the aorta **proximal to the ductus arteriosus** and is not characterized by the four specific tetralogy defects.

Q: Tetralogy of Fallot's includes all except -

ASD. ***ASD*** - An **atrial septal defect (ASD)** is not considered one of the four classic components of **Tetralogy of Fallot (TOF)**. - While other cardiac defects can co-exist with TOF, an ASD is not a primary defining feature of the syndrome. - The **four classic components** of TOF are: VSD, pulmonary stenosis, RVH, and **overriding aorta**. *VSD* - A **ventricular septal defect (VSD)** is one of the four essential components of **Tetralogy of Fallot**, allowing communication between the ventricles. - It is typically a large, **malalignment VSD** that is a critical part of the pathophysiology. *Pulmonary stenosis* - **Pulmonary stenosis** (often infundibular, valvular, or supravalvular) is a key defining feature, leading to obstruction of blood flow from the right ventricle to the pulmonary artery. - The degree of pulmonary stenosis determines the severity of the **cyanosis** and clinical presentation. *RVH* - **Right ventricular hypertrophy (RVH)** develops as a compensatory mechanism due to the increased workload on the right ventricle to pump blood across the stenotic pulmonary valve. - This is a direct consequence of the **pulmonary stenosis** and is one of the four classic components of the syndrome.

Q: True about a 1-year-old child with PDA is –

Symptoms similar to aortopulmonary window. ***Symptoms similar to aortopulmonary window*** - Both **patent ductus arteriosus (PDA)** and an **aortopulmonary window** involve a connection between the aorta and pulmonary artery, leading to **left-to-right shunting**. - This shunting results in similar clinical presentations, such as a **continuous murmur**, signs of **pulmonary overcirculation**, and potential for **congestive heart failure** and **pulmonary hypertension**. *Indomethacin may help in closure* - **Indomethacin** is effective in closing a PDA, but primarily in **premature infants** and typically within the first few weeks of life. - In a **1-year-old child**, the ductus arteriosus has become muscularized and fibrotic, making medical closure with indomethacin ineffective. *Chances of spontaneous closure high* - The highest probability of **spontaneous closure** of a PDA occurs within the **first few days to weeks of life**. - By **1 year of age**, spontaneous closure is highly unlikely, and the PDA is generally considered to require intervention if it is hemodynamically significant. *Endocarditis is rare* - While uncommon, **infective endocarditis** is a well-recognized complication of an uncorrected PDA. - The turbulent blood flow through the shunt creates an environment conducive to bacterial adherence and infection at the pulmonary artery end of the ductus. - This makes endocarditis a definite risk rather than a rare occurrence, particularly in untreated cases.

Q: Child with PDA will NOT have:

This question asks which finding is NOT associated with Patent Ductus Arteriosus (PDA). *Bounding pulses* - **Bounding pulses ARE characteristically present in PDA**, not absent - Result from wide pulse pressure due to diastolic run-off from aorta to pulmonary artery - This is a classic clinical sign of hemodynamically significant PDA ***Necrotizing enterocolitis - needs verification*** - PDA CAN be associated with NEC in premature infants - "Steal phenomenon" diverts blood from splanchnic circulation - However, NEC is multifactorial and not a direct consequence of PDA ***CO₂ washout - needs verification*** - Increased pulmonary blood flow from PDA can affect ventilation - May contribute to respiratory complications - The relationship is complex and context-dependent ***Pulmonary hemorrhage - needs verification*** - Large PDA with significant left-to-right shunt increases pulmonary blood flow - Can lead to pulmonary hemorrhage, especially in preterm infants - Increased pulmonary vascular pressure and volume cause capillary damage **Note:** This question has a structural issue - all listed options except bounding pulses (which IS present in PDA) CAN occur with PDA. The question requires review for medical accuracy and clarity.

Q: A patient presents with cyanosis and pulmonary complications. ECG shows left axis deviation. The most likely diagnosis is:

Tricuspid atresia. ***Correct Answer: Tricuspid atresia*** - Patients with **tricuspid atresia** often present with **cyanosis** due to right-to-left shunting across an atrial septal defect, and **pulmonary complications** can arise depending on pulmonary blood flow. - The ECG finding of **left axis deviation (LAD)** is highly characteristic of tricuspid atresia, as the main blood flow from the right atrium to the left atrium through the atrial septal defect leads to increased volume load on the left ventricle and left ventricular dominance. - LAD in a cyanotic neonate is virtually pathognomonic of tricuspid atresia. *Incorrect: TOF (Tetralogy of Fallot)* - While TOF causes **cyanosis** due to a right-to-left shunt, the ECG typically shows **right axis deviation** and **right ventricular hypertrophy**, not left axis deviation. - Pulmonary complications such as "tet spells" are common, but the distinctive ECG pattern (RAD, not LAD) helps differentiate it. *Incorrect: TAPVC (Total Anomalous Pulmonary Venous Connection)* - **TAPVC** presents with **cyanosis** and pulmonary edema or hypertension depending on the degree of obstruction to pulmonary venous return. - The ECG in TAPVC usually shows **right axis deviation** and **right ventricular hypertrophy** due to increased right-sided pressures, not LAD. *Incorrect: VSD (Ventricular Septal Defect)* - Isolated **VSDs** typically cause a **left-to-right shunt**, leading to pulmonary overcirculation and potentially heart failure, but **cyanosis is not a primary symptom** unless Eisenmenger syndrome develops later. - The ECG in VSD often shows **left ventricular hypertrophy** or biventricular hypertrophy depending on the size and duration of the shunt, but **left axis deviation is not a typical isolated finding** in uncomplicated VSD.

Q: Which of the following is a manifestation of Tetralogy of Fallot?

VSD. **VSD** - A **ventricular septal defect (VSD)** is one of the four cardinal defects comprising Tetralogy of Fallot, allowing for communication between the right and left ventricles [1]. - The size of the VSD is typically large, leading to equalization of pressures between the two ventricles [1]. *Left axis deviation* - **Left axis deviation** is not a typical electrocardiographic finding in Tetralogy of Fallot; instead, right axis deviation is more common due to **right ventricular hypertrophy** [1]. - It is more characteristic of conditions like **left anterior fascicular block** or chronic left ventricular overload. *Left ventricular hypertrophy* - **Left ventricular hypertrophy** is not a characteristic feature of Tetralogy of Fallot; rather, **right ventricular hypertrophy** is a diagnostic component due to the obstruction of the right ventricular outflow tract [1]. - While the left ventricle may be affected by volume changes, it does not typically undergo hypertrophy in Tetralogy of Fallot. *All of the options* - This option is incorrect because, as explained, **left axis deviation** and **left ventricular hypertrophy** are not characteristic manifestations of Tetralogy of Fallot. - Only a **VSD** is one of the core defects in this complex congenital heart condition [1].

Q: Which of the following is NOT a ductus dependent congenital heart disease?

Truncus arteriosus. ***Truncus arteriosus*** - In **truncus arteriosus**, a single great artery arises from both ventricles, supplying both systemic and pulmonary circulation. The **pulmonary blood flow is typically unrestricted**, meaning the ductus arteriosus is not required for survival. - While a VSD is usually present, allowing mixing of blood, the pulmonary blood flow does not depend on the **ductus arteriosus** for patency. - This is the only condition among the options that is **NOT ductus-dependent**. *Tricuspid atresia* - **Tricuspid atresia** is a ductus-dependent lesion because without a patent **ductus arteriosus**, there is inadequate mixing or blood flow to reach either the pulmonary or systemic circulation depending on the anatomic variant. - The **ductus arteriosus** is crucial for survival in the neonatal period, often necessitating prostaglandin infusion to maintain ductal patency. *Tetralogy of Fallot with pulmonary atresia* - In **TOF with pulmonary atresia**, there is complete obstruction of the right ventricular outflow tract, making the **ductus arteriosus** the only source of pulmonary blood flow. - If the **ductus arteriosus closes**, the infant will suffer from severe **cyanosis** due to complete absence of pulmonary blood flow. - Note: Standard TOF without pulmonary atresia is NOT ductus-dependent as some blood reaches the lungs through the stenotic pulmonary valve. *Interrupted Aortic Arch* - **Interrupted Aortic Arch** is a ductus-dependent lesion because postnatal survival depends on a patent **ductus arteriosus** to supply blood flow to the descending aorta and lower body. - Without the **ductus arteriosus**, the lower body lacks systemic blood supply, leading to **shock** and **organ damage**.

Q: Which one of the following does not produce cyanosis in the first year of life -

Atrial septal defect. ***Atrial septal defect*** - An **atrial septal defect (ASD)** typically causes a **left-to-right shunt**, leading to increased blood flow to the lungs rather than systemic hypoxemia, thus not producing cyanosis. - Cyanosis in an ASD usually only occurs if there is significant **pulmonary hypertension** leading to shunt reversal (Eisenmenger syndrome), which is rare in the first year of life. *Truncus arteriosus* - **Truncus arteriosus** involves a single great artery arising from both ventricles, causing a mixing of systemic and pulmonary venous blood. - This mixing results in a significant amount of **deoxygenated blood** entering the systemic circulation, leading to severe cyanosis. *Double outlet right ventricle* - In **double outlet right ventricle (DORV)**, both great arteries (aorta and pulmonary artery) arise mainly from the right ventricle. - Depending on the relationship of the great arteries and the presence of a **ventricular septal defect (VSD)** location, significant deoxygenated blood can enter the systemic circulation, causing cyanosis. *Hypoplastic left heart syndrome* - **Hypoplastic left heart syndrome (HLHS)** is characterized by a severely underdeveloped left ventricle, aorta, and mitral valve. - This condition necessitates a right-to-left shunt through a patent foramen ovale or ductus arteriosus to supply systemic circulation with mixed blood, leading to severe and progressive cyanosis shortly after birth.

Q: All of the following about PDA are true except

More common in males. ***More common in males*** - **Patent Ductus Arteriosus (PDA)** is **more common in females** (female to male ratio of 2:1), thus this statement is incorrect. - The increased prevalence in females is thought to be due to hormonal influences during fetal development. *Common heart lesion in rubella* - PDA is indeed a **common cardiac anomaly associated with congenital rubella syndrome**, especially when infection occurs during the first trimester. - The rubella virus can interfere with the normal closure mechanisms of the ductus arteriosus. *Treatment is closure of defect by ligation and division of ductus* - **Surgical ligation and division of the ductus arteriosus** is a definitive treatment for PDA, particularly in older children or adults. - In neonates, especially premature infants, **indomethacin** (a prostaglandin inhibitor) is often the first-line treatment to induce closure. *Hypoxia and immaturity are important in maintaining the patency* - **Prematurity** is a major risk factor for PDA because the ductus arteriosus in premature infants is less responsive to oxygen-induced constriction and has immature smooth muscle. - **Hypoxia** during fetal life and immediately after birth contributes to maintaining ductal patency by preventing the usual increase in oxygen levels that triggers closure.

Question 1

Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

Accepted Answer

Liver enlargement

Answer

Pedal oedema

Answer

JVP

Answer

Basal crepitations

Question 2

A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets "bluish" when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis?

Accepted Answer

Tetralogy of Fallot

Answer

Atrial septal defect

Answer

Coarctation of aorta, postductal

Answer

Coarctation of aorta, preductal

Question 3

Tetralogy of Fallot's includes all except -

Accepted Answer

ASD

Answer

VSD

Answer

Pulmonary stenosis

Answer

RVH

Question 4

True about a 1-year-old child with PDA is –

Accepted Answer

Symptoms similar to aortopulmonary window

Answer

Indomethacin may help in closure

Answer

Chances of spontaneous closure high

Answer

Endocarditis is rare

Question 5

Child with PDA will NOT have:

Answer

Necrotizing enterocolitis

Answer

CO₂ washout

Answer

Bounding pulses

Answer

Pulmonary hemorrhage

Question 6

A patient presents with cyanosis and pulmonary complications. ECG shows left axis deviation. The most likely diagnosis is:

Accepted Answer

Tricuspid atresia

Answer

TOF

Answer

TAPVC

Answer

VSD

Question 7

Which of the following is a manifestation of Tetralogy of Fallot?

Accepted Answer

VSD

Answer

Left axis deviation

Answer

Left ventricular hypertrophy

Answer

All of the options

Question 8

Which of the following is NOT a ductus dependent congenital heart disease?

Accepted Answer

Truncus arteriosus

Answer

Tricuspid atresia

Answer

Tetralogy of Fallot with pulmonary atresia

Answer

Interrupted Aortic Arch

Question 9

Which one of the following does not produce cyanosis in the first year of life -

Accepted Answer

Atrial septal defect

Answer

Truncus arteriosus

Answer

Double outlet right ventricle

Answer

Hypoplastic left heart syndrome

Question 10

All of the following about PDA are true except

Accepted Answer

More common in males

Answer

Common heart lesion in rubella

Answer

Treatment is closure of defect by ligation and division of ductus

Answer

Hypoxia and immaturity are important in maintaining the patency

Cardiology — MCQs

Cardiology — MCQs

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